Blue Cross and Blue Shield of North Carolina v. United States

131 Fed. Cl. 457, 2017 U.S. Claims LEXIS 334, 2017 WL 1382976
CourtUnited States Court of Federal Claims
DecidedApril 18, 2017
Docket16-651C
StatusPublished
Cited by5 cases

This text of 131 Fed. Cl. 457 (Blue Cross and Blue Shield of North Carolina v. United States) is published on Counsel Stack Legal Research, covering United States Court of Federal Claims primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Blue Cross and Blue Shield of North Carolina v. United States, 131 Fed. Cl. 457, 2017 U.S. Claims LEXIS 334, 2017 WL 1382976 (uscfc 2017).

Opinion

The Patient Protection and Affordable Care Act; Risk Corridors; RCFC 12(b)(1), Subject-matter Jurisdiction; RCFC 12(b)(6), Failure to State a Claim; Ripeness.

MEMORANDUM OPINION AND ORDER

GRIGGSBY, Judge

I. INTRODUCTION

Plaintiff, Blue Cross and Blue Shield of North Carolina (“Blue Cross”), brings this action alleging statutory, breach of contract and takings claims against the United States to recover certain payments allegedly due under the Patient Protection and Affordable Care Act, Pub. L. No. 111-148,124 Stat. 119 (Mar. 23, 2010) (the “ACA”). See generally Compl. The government has moved to dismiss this action for lack of subject-matter jurisdiction and for failure to state a claim upon which relief can be granted, pursuant to Rules 12(b)(1) and 12(b)(6) of the Rules.of the United States Court of Federal Claims (“RCFC”). See generally Def. Mot. For the reasons discussed below, the Court GRANTS-IN-PART and DENIES-IN-PART the government’s motion to dismiss.

*462 II. FACTUAL AND PROCEDURAL BACKGROUND

A. Factual Background 1

1. Overview

Plaintiff, Blue Cross, brings this action alleging statutory, breach of contract and takings claims against the government to recover certain payments allegedly due under the ACA’s Risk Corridors Program. See generally Compl. The Risk Corridors Program is a three-year, temporary premium stabilization program, in which the government and Qualified Health Plans (“QHPs”), like Blue Cross, “share in the risk associated with the new marketplace’s uncertainty for each of the temporary program’s three years: 2014, 2015 and 2016” (the “Risk Corridors Program”). Id. at ¶¶ 6; see also id. at 33; 42 U.S.C. § 18062. Blue Cross participated in the Risk Corridors Program during 2014, 2015 arid 2016. Id. at ¶¶ 34-44. Under the Risk Corridors Program, Blue Cross and other QHPs may receive money from the United States Department of Health and Human Services (“HHS”) to help reduce financial uncertainty during the initial years of the ACA. Compl. at ¶ 21. To date, Blue Cross has received only a portion of such payments for 2014 (the “Risk Corridors Program Payments”). 2 Compl. at ¶¶ 135-36.

Blue Cross asserts five claims in the complaint to recover the full amount of its 2014 Risk Corridors Program Payments. First, Blue Cross alleges that the government violated Section 1342 of the ACA and its implementing regulations, 45 C.F.R. § 153.510, by failing to make full, annual Risk Corridors Program Payments to Blue Cross. Id. at ¶¶ 154-65. Second, Blue Cross alleges that the government also breached its QHP Agreement with the government by failing to make these payments in full, upon an annual basis. Id. at ¶¶ 166-79. Third, Blue Cross contends that the government also breached implied-in-fact contracts with Blue Cross to make full, annual Risk Corridors Program Payments. Id. at ¶¶ 180-98.

In addition, Blue Cross contends that the government breached the covenant of good faith and fair dealing implied in its alleged express and implied contracts with the government, by failing to make these payments. Id. at ¶¶ 199-210. Lastly, Blue Cross alleges that the government has improperly taken its property interest in a statutory, regulatory and contractual right to receive full, annual Risk Corridors Program Payments, in violation of the Fifth Amendment of the United States Constitution. Id. at ¶¶ 211-18. Blue Cross also requests that the Court declare that the government must make full, annual Risk Corridors Program Payments for calendar years 2015 and 2016. Compl. at Prayer for Relief.

2. The Affordable Care Act

As background, Congress enacted the Patient Protection and Affordable Care Act in 2010. See Pub. L. No. 111-148. The goal of the ACA is to increase access to affordable, quality health insurance coverage for all Americans. King v. Burwell, — U.S. -, 135 S.Ct. 2480, 2485, 192 L.Ed.2d 483 (2015).

The ACA contains three key reforms to the health insurance system: (1) to prohibit health insurance companies from denying coverage or setting premiums based upon health status or medical history; (2) to require individuals to maintain health insurance coverage or make a payment to the Internal Revenue Service; and (3) to provide federal insurance subsidies in the form of *463 premium tax credits and cost sharing reductions to make insurance more affordable to eligible consumers. Id. at 2486-87 (citing 42 U.S.C. §§ 300gg, 300gg-l(a), 18081-82,18091 (2016); 26 U.S.C. §§ 36B, 5000A (2016)); see also 42 U.S.C. § 18071 (2016). To implement the aforementioned reforms, the ACA creates American Health Benefit Exchanges (“Exchanges”), which are virtual marketplaces in each state where individuals and small groups can purchase health insurance coverage. 42 U.S.C. §§ 18031-41 (2016). The Exchanges provide, among other things, a centralized location for consumers to enroll in qualified health plans and competitive marketplaces for insurers to compete for business. Id.

All plans offered through the Exchanges must be QHPs, meaning that such a plan must provide “essential.health benefits” and comply with other regulatory parameters such as provider network requirements, benefit design rules, and cost sharing limitations. See 42 U.S.C. § 18021; 45 C.F.R. §§ 155-56. As part of the process to ensure that issuers that participate in the Exchanges comply with the ACA’s requirements, HHS requires issuers to, among other things, execute an agreement known as a “Qualified Health Plan Certification Agreement and Privacy and Security Agreement” (the “QHP Agreement”). 45 C.F.R. § 155.260(b)(2). In the QHP Agreement, QHP issuers agree to, among other things, adhere to certain privacy and security standards when conducting transactions on the federally-facilitated Exchanges. Id.; see e.g., Compl. at Exs. 2-4.

3. The Risk Corridors Program

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Cite This Page — Counsel Stack

Bluebook (online)
131 Fed. Cl. 457, 2017 U.S. Claims LEXIS 334, 2017 WL 1382976, Counsel Stack Legal Research, https://law.counselstack.com/opinion/blue-cross-and-blue-shield-of-north-carolina-v-united-states-uscfc-2017.